Instructions

Partner details

This form lets us know about your partner’s details.

When to use this form Use this form if you are:

• claiming a payment or concession card and cannot provide your partner’s details
within your claim
• currently getting a payment or concession card and cannot provide your partner’s
details over the phone or in person. If you can provide your partner’s details over the
phone or in person, your partner must be with you when you call or attend in person
• currently getting Parenting Payment at the single rate and you are still the principal
carer of a child under 6 years of age.
You may be required to complete this form if we have assessed you as having a partner.
Do not use this form if you are:
• currently getting Parenting Payment at the single rate and you are no longer the
principal carer of a child under 6 years of age, you must claim another payment.
For more information, go to [Link]/paymentfinder
www.

• living outside Australia. Complete a Partner details (AUS174) form instead. If you do not
have this form, go to [Link]/forms
www.

Having a partner You have a partner if we consider you a member of a couple. We consider you a member
of a couple if you are either:
• married
• in a registered relationship, or
• in a de facto relationship.
A registered relationship is where your relationship is registered under a law of a state
or territory. A de facto relationship is where you and your partner are in a relationship
similar to a married couple but are not married or in a registered relationship.
We may still consider you a member of a couple if you are not physically living with your
partner. For example, your partner may fly-in fly-out or live away for work, like military or
oil rig workers.
If you have been separated from your current partner, you need to tell us the date you most
recently reconciled for us to correctly assess any entitlement to payments or services.
For more information, go to [Link]/moc
www.

What else you may Your partner may need to provide identity documents. For a list of acceptable documents,
need to provide go to [Link]/identity
www.

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Notes—1 of 2
Partner Permitted to Allowing your partner to enquire on your behalf may save you time when dealing with
Enquire us. It will let you and your partner use more self-service functions online and over the
phone.
If you give your partner permission to enquire, it will allow your partner to ask questions
about your Centrelink payments and services. They could ask us:
• your current rate of payment
• the reason your payment has stopped
• the reason your payment has gone up or down, for example, income and assets,
debt and back payment information.
They can tell us how much employment income you were paid, changes in your
circumstances and view your details online.
They cannot:
• act on your behalf with Centrelink
• apply for payments for you
• complete and sign forms and statements on your behalf
• come to appointments for you.
You have a right to have your personal information kept private. For more information,
go to [Link]/privacy
www.

You can give or remove who you give permission to enquire to, at any time. You can
do this online or by calling us.
If your partner would like to give you permission to enquire on their behalf, they can do
this via their Centrelink online account or by calling us.

Additional services If you need to call us, go to [Link]/phoneus

www.

To speak to us in your language, call 131 202.

Call charges may apply.
We can translate documents you need for your claim or payment for free.
If you have a hearing or speech impairment, you can contact the TTY service
Freecall™ 1800 810 586. A TTY phone is required to use this service.

Returning this form Return this form and any supporting documents:
• online (excluding identity documents) using your Centrelink online account.
For more information, go to [Link]/centrelinkuploaddocs
www.

• in person at one of our service centres, if you are unable to use your Centrelink online
account.
Important note: If you are making a claim, you must return this form and all supporting
documents at the same time you lodge your claim form. If you do not return all documents,
your claim may not be accepted. The only exception will be if you are waiting for medical
evidence or other documents from a third party.

Mod(P).2201
Notes—2 of 2
 Instructions

Partner details

Filling in this form 5 Has your phone number changed since you last told us?
No Go to next question
You can complete this form on your computer, print and sign it.
Yes Phone number
If you have a printed form:
• Use black or blue pen.
• Print in BLOCK LETTERS.
• Where you see a box like this Go to 1 skip to the question
number shown.
6 Do you give permission for your partner to speak with us on
your behalf?
For more information, read page 2 of the Notes.
About you
No
1 Your Customer Reference Number (if known) Yes

7 Read this before answering the following question.

Carer Allowance is a fortnightly supplement if you give
2 Your name additional daily care to someone who has a disability,
Family name serious illness, or is frail aged.
Commonwealth Seniors Health Card is a concession card
to get cheaper health care and some discounts if you have
First given name reached Age Pension age.
Low Income Health Care Card is a concession card to get
cheaper health care and some discounts if you are on a low
Second given name income.

Do you only get or are you only claiming:

• Carer Allowance
3 Your date of birth • Commonwealth Seniors Health Card, or
• Low Income Health Care Card?
/ /
If you are only getting or claiming any of the above, tick ‘Yes’.
If you are getting another Centrelink payment (with or without
4 Tick one of the boxes below to tell us about your relationship any of the above), tick ‘No’.
status right now.
For more information on relationship status, read page 1 of No Go to next question
the Notes. Yes Go to 11
If you have ever been separated, give the date that you most
recently got back together (reconciled) with your partner. 8 Read this before answering the following question.
Married Date married or last Family Tax Benefit is a 2 part payment that helps with the
reconciled with your partner cost of raising children.
/ / Child Care Subsidy is assistance to help you with the cost of
child care.
Go to next question
Do you only get Family Tax Benefit and/or Child Care Subsidy?
Registered relationship Date registered or last
(your relationship is reconciled with your partner If you are only getting Family Tax Benefit and/or Child Care
registered under Australian Subsidy, tick ‘Yes’.
/ /
state or territory law) If you are getting another Centrelink payment (with or without
Go to next question Family Tax Benefit and/or Child Care Subsidy), tick ‘No’.
De facto Date you started your No Go to next question
(your relationship is similar relationship or last
reconciled with your partner Yes Go to 11
to a married couple but
you are not married or in a / /
registered relationship)
Go to next question
CLK0Mod(P) 2201

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9 Has your address or accommodation details changed since you About your partner
last told us?
No Go to next question 12 Your partner’s Customer Reference Number (if known)
Yes You will need to complete and return an
Accommodation details (Mod AC) form.
If you do not have this form, go to
13 Your partner’s name
www.

[Link]/forms
Go to next question Mr Mrs Miss Ms Other
Family name
10 Have there been any changes to your income or assets since
the date you became partnered or last reconciled, that you
First given name
have not already told us about?
No Go to next question
Yes Second given name
You will need to complete and return an
Income and Assets (Mod iA) form.
If you do not have this form, go to
www.

[Link]/forms
Go to next question 14 Has your partner been known by any other name(s)?
Include:
• name at birth
11 Is your partner currently getting an income support payment • name before marriage
from us? • previous married name
An income support payment is a regular payment that helps • Aboriginal or skin name
you with living costs. • alias
For information on the relevant income support payments, • adoptive name
go to [Link]/incomesupportpayments
www.
• foster name.

No Go to next question No Go to next question

Yes Yes Give details below
You will need to complete and return an
Income and Assets (Mod iA) form. 1 Other name
If you do not have this form, go to
www.

[Link]/forms
Go to next question

Type of name (for example, name at birth)

2 Other name

Type of name (for example, name before marriage)

If you need more space, provide a separate sheet with details.

15 Your partner’s gender

Male
Female

16 Your partner’s date of birth

/ /

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17 Does your partner need an interpreter when dealing with us? 23 Why is your partner not living with you?
This includes an interpreter for people who have a hearing or Your/your partner’s employment
speech impairment.
Your/your partner’s illness
No Go to 20
You are/your partner is in respite care
Yes Go to next question
You are/your partner is in
psychiatric confinement
18 What is your partner’s preferred spoken language?
You are/your partner is in prison
Other Give details below

19 What is your partner’s preferred written language?

20 Read this before answering the following question. 24 Period your partner is not living with you
Providing a mobile phone number or an email address means From / /
your partner may receive SMS or emails from us. To read the
terms and conditions, go to [Link]/em
www.

To / / OR Indefinite
Your partner’s contact details
Home phone number ( ) 25 Does your partner only get
• Carer Allowance, or
Is this a silent number? No Yes
• Commonwealth Seniors Health Card?
Mobile phone number No Go to next question
Yes Go to 83
Work phone number ( )

Alternative phone number ( )

26 Is your partner currently claiming or getting an income support
payment or a Low Income Health Care Card from us?
Email
An income support payment is a regular payment that helps
you with living costs.
For information on the relevant income support payments,
go to [Link]/incomesupportpayments
21 Is your partner currently living, or will live, in the same home
www.

as you? No Go to 28
No Go to next question Yes Go to next question
Yes Go to 25
27 Read this before answering the following question.
22 What is your partner’s address? As your partner is receiving an income support payment or
Your partner’s permanent address a Low Income Health Care Card, we need to know if your
partner’s income and assets have changed so we can work out
your entitlements.

Have there been any changes to your partner’s income or assets

since the date you became partnered or last reconciled, that you
Postcode
have not already told us about?
Your partner’s postal address (if different to above) No Go to 83
Yes You will need to complete and return an
Income and Assets (Mod iA) form.
If you do not have this form, go to
www.

[Link]/forms
Postcode Go to 83

Mod(P).2201
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28 Read this before answering the following question. 32 Is your partner an Australian citizen who was born in Australia?
This question is voluntary and will not affect any payments No Go to next question
you or your partner get or are claiming. If you do answer, the Yes Go to 38
information will help us to continue to improve services to
Aboriginal and Torres Strait Islander Australians.
33 What is your partner’s country of birth?
Is your partner of Aboriginal or Torres Strait Islander Australian
descent?
If they are of both Aboriginal and Torres Strait Islander
Australian descent, tick both ‘Yes’ boxes.
34 What is your partner’s country of citizenship?
No Australia Date citizenship granted
Yes – Aboriginal Australian / / Go to 38
Yes – Torres Strait Islander Australian
Other Give details below
Country of citizenship
29 Read this before answering the following question.
This question is voluntary and will not affect any payments
you or your partner get or are claiming. If you do answer, Date citizenship granted
the information will help us to continue to improve services
to people of Australian South Sea Islander descent. / /
Australian South Sea Islanders are the descendants of
Pacific Islander labourers brought from the Western Pacific 35 Has your partner ever lived in Australia?
in the 19th Century.
No Go to 39
Is your partner of Australian South Sea Islander descent? Yes Go to next question
No
Yes 36 What type of visa did your partner arrive on?
Permanent Go to next question
30 What country is your partner currently living in? Temporary Go to next question
The country of residence is where your partner normally lives New Zealand passport Go to 38
on a long term basis. (Special Category visa)
Not sure Go to 38
Australia Go to next question
Other Country of residence 37 Your partner’s current visa details
Visa sub class Date visa granted
/ /

31 Has your partner ever travelled outside Australia, including 38 Read this before answering the following question.
short trips and holidays?
We need to know if your partner has lived in any countries
This question will help us to verify their Australian residence. other than Australia. ‘Lived’ means where your partner or their
family made their home or spent a long period of time – it does
No Go to next question not include places your partner visited for a holiday.
Not applicable – never Go to next question Has your partner ever lived outside Australia for any period?
travelled to Australia
Yes Give details below No Go to next question
Yes List all countries your partner has lived in since
Year last entered Australia
birth and the date they started living in each country.
Include when your partner started living in Australia.
Passport number Do not include short trips or holidays.
Country Date from
Country of issue / /
/ /
/ /

If you need more space, provide a separate sheet with details.

Mod(P).2201
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39 Read this before answering the following questions. Continued
You may not be paid if your partner does not give us your Income from any income stream products
tax file number (TFN). If your partner does not have a TFN,
or does not know what it is, they can apply for one through An income stream product is a regular series of payments
the Australian Taxation Office. which may be made for a lifetime or a fixed period by:
In giving us your partner’s TFN in relation to this claim • a financial institution
they authorise us to use their TFN for other social security • a retirement savings account
payments and services in future where necessary. • a superannuation fund
• a Self Managed Superannuation Fund (SMSF)
Has your partner given us their tax file number before? • a Small APRA Fund (SAF).
No Go to next question Types of income streams include:
• account-based pension (also known as allocated
Not sure Go to next question
pension)
Yes Go to 41 • market-linked pension (also known as term allocated
pension)
40 Does your partner have a tax file number? • annuities
• defined benefit pension (for example, ComSuper
No Go to [Link]
www.
pension, State Super pension)
Go to next question • superannuation pension (non-defined benefit).

Yes Your partner’s tax file number

Payments from an authority or agency outside Australia
Include pensions from other countries, benefits,
allowances, superannuation, compensation and war
41 Do you only get: related payments.
• Family Tax Benefit and/or Child Care Subsidy You must include details of pensions, allowances and
• Commonwealth Seniors Health Card? other payments even if they are not taxable in the
country of payment.
No Go to next question
Yes Go to 83 Money from any boarders or lodgers living with you and/or
your partner
Include boarders or lodgers who live with you and/or
42 Does your partner have any income and/or assets listed below? your partner or in accommodation at the property you
and/or your partner lives in (for example, granny flat).
Include income in and/or outside Australia.
Do not include immediate family members
Tick all that apply (son, daughter, parent/guardian).
Bonds or debentures A lump sum payment received in the last 12 months that
Money on loan to another person or organisation you have not already advised on this form
Shares, options or rights in public companies not listed on Do not include:
a stock exchange • compensation, insurance or damages lump sum
Managed investments payments
• funding from the National Disability Insurance
Include: Scheme (NDIS).
• investment trusts
• personal investment plans Your partner has given away, sold for less than their market
• life insurance bonds value, or surrendered a right to, any cash, assets, property
• friendly society bonds. or income in the last 5 years
Do not include: Include forgiven loans and shares in private companies.
• conventional life insurance policies
• investment purchased with a margin loan.
43 Did you tick any boxes at question 42?
No Go to next question
Yes You will need to complete and return an
Income and Assets (Mod iA) form.
Continued 
If you do not have this form, go towww.

[Link]/forms
Go to 83

Mod(P).2201
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 Employment related income Continued
2 Employer’s name
44 Is your partner currently paid or expecting to be paid any
income from work other than self-employment?
No Go to 46 Address
Yes Give details below
Provide copies of payslip(s) from the date you
became partnered, if you have not already
told us your partner’s income. Postcode
Phone number
1 Employer’s name

Australian Business Number (ABN)

Address

Is this work:
Full-time Part-time Seasonal Casual
Postcode
Personnel, service or
Phone number clock-card number
Hours worked
per fortnight
per fortnight
Australian Business Number (ABN) Gross amount paid
$ per fortnight
per fortnight (before tax
and other deductions)
Is this work: Do they get the same amount each pay day?
Full-time Part-time Seasonal Casual No Yes
Personnel, service or
clock-card number If you need more space, provide a separate sheet with details.
Hours worked
per fortnight
per fortnight
Gross amount paid
$ per fortnight
45 Read this before answering the following question.
per fortnight (before tax Fringe benefits – means a benefit received as part of
and other deductions) employment income but not as a wage or salary.
Do they get the same amount each pay day?
Does your partner get any fringe benefits provided by an
No Yes
employer?
Include:
• use of a car as part of a salary package
• rent/mortgage paid
• home phone
• school fees for children
• child care expenses paid
• health insurance premiums.

No Go to next question
Yes
Provide a copy of the details that show the
type of fringe benefit, its value and if the
amount is ‘grossed up’ or not ‘grossed up’.

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46 Are you filling in this form as part of your claim for one of the 49 In the last 12 months, has your partner stopped working for
following payments: any employers (including self-employment)?
• Carer Payment No Go to next question
• Disability Support Pension (including Disability Support
Pension Blind if claiming Rent Assistance) Yes Give details below
• Farm Household Allowance? Provide documents which confirm:
• that your partner stopped work
No Go to 48
(for example, Employment Separation
Yes Go to next question Certificate (SU001) form or letter from the
employer), or
• your partner’s business has stopped
47 Read this before answering the following question. trading.
Seasonal work is work that is available for part or parts of If you do not have this form, go to
the year at approximately the same time each year.
www.

[Link]/forms
Contract work is any intermittent work that is performed
under a contract for a specific function and/or period
including sub-contract work. 1 Employer or business name
Intermittent work is work that is available from time to time.
This includes work that:
• can reasonably be predicted to end or not be available for Australian Business Number (ABN)
a period
• is less than 1 year in duration and does not accrue leave
entitlements.
2 Employer or business name
In the last 6 months, has your partner done any seasonal,
contract or intermittent work?
No Go to 52 Australian Business Number (ABN)
Yes You will need to complete and return a
Seasonal, Contract and Intermittent Work
Details (SU496) form. If you need more space, provide a separate sheet with details.
If you do not have this form, go towww.

[Link]/forms
Go to 52 50 In the last 12 months, did your partner get or do they expect to
get, any leave entitlement payments from an employer?

48 Are you getting one of the following payments: Include:

• Austudy • annual leave
• Disability Support Pension (including Disability Support • maternity leave
Pension Blind claiming Rent Assistance) • long service leave or sick leave your partner got when
• Farm Household Allowance they stopped work
• JobSeeker Payment • entitlements that your partner cashed in before they
• Parenting Payment stopped work
• Special Benefit • money in a long service leave fund or scheme that your
• Youth Allowance? partner has not cashed in.

No Go to 52 No Go to next question
Yes Go to next question Yes Give details below and next column
Provide documents which confirm each
leave entitlement payment (for example,
Employment Separation Certificate (SU001)
form or letter from the employer).
If you do not have this form, go towww.

[Link]/forms

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 Continued Business interests
1 Type of leave entitlement payment
52 Is your partner involved in any type of business?
Include:
Amount (before tax and Number of working days • farming
other deductions) covered by the payment • self-employed
• sole trader
$
• partnership
Date paid or date payable • sub-contractor.
/ / For more information, go to www.

[Link]/businesstypes
Employer’s details
Name of business No Go to next question
Yes You will need to complete and return a
Business details (Mod F) form.
Australian Business Number (ABN) If the business owns real estate you will
also need to complete and return a
Real estate details (Mod R) form for each
Phone number property.
If you do not have these forms, go to www.

[Link]/forms

2 Type of leave entitlement payment

53 Read this before answering the following question.
Your partner may be, or has been involved in a trust as:
Amount (before tax and Number of working days • a trustee
other deductions) covered by the payment
• an appointor
$ • a beneficiary
or has:
Date paid or date payable
• made a loan to a private trust
/ / • made a gift of cash, assets, or private property to a
private trust in the last 5 years
Employer’s details
• relinquished involvement in a private trust in the last
Name of business 5 years
• a private annuity
• a life interest
Australian Business Number (ABN)
• an interest in a deceased estate.
A private trust includes a non-complying Self Managed
Superannuation Fund (SMSF) or a non-complying Small
Phone number APRA Fund (SAF).
For more information, go to www.

[Link]/trustsandcompanies
If you need more space, provide a separate sheet with details.
Is, or has, your partner been involved in a private trust in any of
the ways detailed above?
51 Did your partner get a redundancy payment in the last 2 years? No Go to 59
No Go to next question Yes Go to next question
Yes Provide documents which confirm any
redundancy payments (for example, 54 Is the private trust now vested?
Employment Separation Certificate (SU001)
form or letter from the employer). No Go to 56
If you do not have this form, go to Yes
www.

You will need to provide a copy of evidence of

[Link]/forms the vesting.
Go to next question

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55 Has your partner made any type of gift involving a private trust 60 Is the private company now deregistered with the Australian
(either active or vested) in the last 5 years? Securities and Investments Commission (ASIC)?
Include: No Go to 62
• forgiving a loan Yes
• transfer of assets to or from a trust for less than their value You will need to provide a copy of evidence of
deregistration.
• forgoing distributions.
Go to next question
No Go to 59
Yes Go to next question 61 Has your partner made any type of gift involving a private
company (either registered or deregistered) in the last 5 years?
56 Has your partner completed a Private Trust (Mod PT) form or a Include:
Special Disability Trust (Mod SDT) form in the last 5 years? • forgiving a loan
No Go to next question • transfer of assets to or from a private company for less
than their value
Yes Go to 58
• forgoing distributions.

57 Is the private trust a Special Disability Trust (SDT)? No Go to 64

No Yes Go to next question
You will need to complete and return a
Private Trust (Mod PT) form.
If you do not have this form, go to www.
62 Has your partner completed a Private Company (Mod PC) form in
[Link]/forms the last 5 years?
Go to 59 No You will need to complete and return a
Private Company (Mod PC) form.
Yes You will need to complete and return a If you do not have this form, go to
Special Disability Trust (Mod SDT) form.
www.

[Link]/forms
If you do not have this form, go to www.

Go to 64
[Link]/forms
Go to 59 Yes Go to next question

58 Has your partner provided the most recent financial documents 63 Has your partner provided the most recent financial documents to
to us? us?
No No Provide copies of the most recent financial
Provide copies of the most recent financial
documents (for example, an Income Tax documents (for example, an income tax
Return). return).
Go to next question Go to next question

Yes Go to next question Yes Go to next question

59 Read this before answering the following question.

Your partner may be, or has been in the last 5 years:
• a director of a company
• a shareholder of a company
or has:
• made a loan to a private company
• transferred shares in a private company
• made a gift of cash, assets or property to a private
company.
For more information, go to www.

[Link]/trustsandcompanies

Is, or has, your partner been involved with a private company in

any of the ways detailed above?
No Go to 64
Yes Go to next question

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 Compensation Other money received

64 Read this before answering the following question. 67 Does your partner get payments from outside Australia?
Compensation, insurance and damages include: Include:
• worker’s compensation • pensions from other countries
• motor vehicle • benefits
• criminal injuries/victims compensation • allowances
• sporting injury • superannuation
• public liability • compensation, and
• medical negligence • war related payments.
• personal accident and sickness insurance You must include details of pensions, allowances and other
• income replacement insurance. payments even if:
Has your partner ever: • they are not taxable in the country of payment, and/or
• received • your partner has arranged for their payment to be made
to a third party.
• claimed, or
• been able to claim
No Go to next question
compensation, insurance and/or damages?
Yes Give details below
No Go to 67
Provide a copy of the document (for example,
Yes Go to next question latest pension certificate – not a bank
statement) from each issuing authority or
65 Has your partner told us about this before? agency which gives details including the
gross amount in the foreign currency and
No frequency of the payment.
You will need to complete and return a
Compensation and damages (Mod C) form.
If you do not have this form, go to
www.
1 Type of payment
[Link]/forms
Go to next question
Country which pays it?
Yes Go to next question

Who pays it?

66 Does your partner get payments from an income protection
policy?
No Go to next question Date commenced (if known)
Yes / /
Provide a copy of the policy document and
the latest statement for this policy.
2 Type of payment

Country which pays it?

Who pays it?

Date commenced (if known)

/ /

If you need more space, provide a separate sheet with details.

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 Bank accounts Continued
3 Name of bank,
68 Give details of all accounts held by your partner in banks, building society
building societies or credit unions. or credit union
Branch number
Include:
(BSB)
• savings accounts
• cheque accounts Account number
• term deposits (this may not be your
card number)
• joint accounts
• accounts held in trust or under any other name Current balance of
• money held in church or charitable development funds. account
Accounts and term deposits outside Australia should be Currency
included, with the current balance in the type of currency in if not AUD
which it is invested. We will convert this into Australian dollars. Your partner’s share %
Do not include:
• shares 4 Name of bank,
• managed investments building society
• an account used exclusively for funding from the National or credit union
Disability Insurance Scheme (NDIS). Branch number
(BSB)
Provide evidence from your partner’s financial institution Account number
that shows the current account balance, BSB code, (this may not be your
account number and account holder name(s) for each card number)
account held. Copies can be provided.
ATM slips are not acceptable. Current balance of
account
1 Currency
Name of bank,
if not AUD
building society
or credit union Your partner’s share %
Branch number
(BSB)
5 Name of bank,
Account number building society
(this may not be your or credit union
card number) Branch number
Current balance of (BSB)
account Account number
Currency (this may not be your
if not AUD card number)
Your partner’s share % Current balance of
account
2 Currency
Name of bank,
if not AUD
building society
or credit union Your partner’s share %
Branch number
(BSB)
6 Name of bank,
Account number building society
(this may not be your or credit union
card number) Branch number
Current balance of (BSB)
account Account number
Currency (this may not be your
if not AUD card number)
Your partner’s share % Current balance of
account
Currency
if not AUD
Your partner’s share %

If you need more space, provide a separate sheet with details.

Mod(P).2201
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 Assets 71 Does your partner own, partly own or have a financial interest
in any boats or caravans/motor homes?
69 What is your partner’s estimate of the current market value of Do not include a boat or caravan that your partner lives in.
their household contents and personal effects?
No Go to next question
The current market value is the price that your partner
would expect to get if they sold the item. It is not the Yes Give details below
replacement or insured value.
1 Type of asset Make
Include: (for example, boat) (for example, Quintrex)
• all furniture (including soft furnishings such as curtains),
antiques and works of art
• electrical appliances such as televisions and fridges
Model (for example, Coastrunner) Year
• jewellery for personal use and hobby collections
(for example, stamps, coins).
Do not include: Balance of loan(s) taken to
• fixtures such as stoves and built-in items. purchase
Current market value
$ $
Balance of loan(s) taken
Current market value to purchase Your partner’s
%
share
$ $
2 Type of asset Make
Your partner’s
% (for example, caravan) (for example, Jayco)
share

70 Does your partner own, partly own or have a financial interest Model (for example, Heritage) Year
in any motor vehicles, motor cycles or trailers?
No Go to next question
Balance of loan(s) taken to
Yes Give details below Current market value purchase
1 Type of asset Make $ $
(for example, car) (for example, Ford)
Your partner’s
%
share
Model (for example, Focus) Year
If you need more space, provide a separate sheet with details.

Balance of loan(s) taken to

Current market value purchase 72 Does your partner own, or are they buying, or do they have a life
interest in their home?
$ $
A life interest means your partner has the right to reside in
Your partner’s their home for life.
%
share
No Go to 76
2 Type of asset Make
Yes Go to next question
(for example, car) (for example, Holden)

73 Is the home on a block of land larger than 2 hectares (5 acres)?

Model (for example, Astra) Year
No Go to next question
Yes You will need to complete and return a
Balance of loan(s) taken to Real estate details (Mod R) form.
Current market value purchase If you do not have this form, go to www.

[Link]/forms
$ $
Go to 75
Your partner’s
%
share

If you need more space, provide a separate sheet with details.

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74 Does the property that your partner lives on have more than Superannuation
one title document?
No Go to next question 78 Read this before answering the following question.
Yes You will need to complete and return a Answer this question only if your partner is Age Pension age
Real estate details (Mod R) form. otherwise, Go to 79
If you do not have this form, go to
www.

To work out if they are Age Pension age, use the table below.
[Link]/forms
Date of birth Qualifying age at
1 July 1955 to 31 December 1956 66 years and 6 months
75 Is any part of the home property used for income From 1 January 1957 67 years
producing purposes?
Do not include rent from boarders or lodgers. Does your partner have any money invested in superannuation
in Australia where the fund is not paying a pension?
No Go to next question Include:
Yes You will need to complete and return a • superannuation funds such as:
Real estate details (Mod R) form. – retail
– industry
If you do not have this form, go to
www.

– corporate
[Link]/forms
– employer
– public sector
• retirement savings accounts
76 Does your partner have an interest in any other real estate in • Self Managed Superannuation Funds (SMSF) and Small
and/or outside Australia? APRA Funds (SAF) if the funds are complying.
No Go to 78 SPIN code – is commonly used for fund managers to identify
Yes Go to next question superannuation products.
No Go to next question
77 How many other properties in and/or outside Australia does Yes Give details below
your partner own or have a interest in?
Provide a copy of the latest statements for
superannuation funds and retirement savings
accounts. If your partner has a SMSF or SAF,
You will need to complete and return a provide the financial statement including
Real estate details (Mod R) form for each property. income tax return and member statement.
If you do not have this form, go to
www.

1 Name of institution/fund manager or SPIN code

[Link]/forms

Name of fund

Product reference number Date of joining/investment

/ /
Current market value
$

2 Name of institution/fund manager or SPIN code

Name of fund

Product reference number Date of joining/investment

/ /
Current market value
$

If you need more space, provide a separate sheet with details.

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 Financial assets 80 Does your partner have a life insurance policy that can be
cashed in?
79 Does your partner own any shares, options, rights, convertible Include:
notes or other securities listed on a stock/securities exchange
• policies with a surrender value (for example, whole of life,
in and/or outside Australia? paid up and endowment policies).
Include: Do not include:
• futures • friendly society bonds
• options • life insurance bonds
• derivatives • details of home, contents, car, mortgage or similar
• rights policies.
• convertible notes.
Do not include: No Go to next question
• managed investments Yes Give details below
• investments purchased with a margin loan.
Provide a copy of the policy document and
the latest statement for each policy.
No Go to next question
Yes Give details below 1 Name of insurance company
Provide a copy of the latest statement
detailing the shareholding in each company.
Policy number Surrender value
1 Name of the public company or ASX code
$
Your partner’s
%
Number of shares held Country if not Australia share

2 Name of insurance company

Your partner’s
%
share
Policy number Surrender value
2 Name of the public company or ASX code
$
Your partner’s
%
Number of shares held Country if not Australia share

If you need more space, provide a separate sheet with details.

Your partner’s
%
share

3 Name of the public company or ASX code

Number of shares held Country if not Australia

Your partner’s
%
share

4 Name of the public company or ASX code

Number of shares held Country if not Australia

Your partner’s
%
share

If you need more space, provide a separate sheet with details.

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 Other income and assets 82 Does your partner own any other assets (in or outside Australia)
that you have not already told us about on this form?
81 Does your partner get any payments that you have not already
Include:
told us about on this form?
• taxi plates
Include: • time share
• Department of Veterans’ Affairs (DVA) payments • racehorses
• New Enterprise Incentive Scheme (NEIS) Allowance • greyhounds
• gratuities • travellers cheques
• match or sporting payments • crypto currency (for example, bitcoin)
• non-monetary payments for services • collectables (for example, stamps, coins, wine, art,
• scholarships, educational assistance or allowance antiques)
• any other income. • commercial licences (for example, fishing, hunting)
Do not include: • water assets including rights, allocations or licences not
• funding from the National Disability Insurance Scheme associated with land owned by your partner.
(NDIS) Do not include an account used exclusively for funding from
• Parental Leave Pay the National Disability Insurance Scheme (NDIS).
• Dad and Partner Pay.
No Go to next question
No Go to next question Yes Give details below
Yes Give details below
1 Description of asset
Provide a copy of the most recent statement/
certificate that gives details for each type of
payment.
Balance of loan(s)
Current market value taken to purchase
1 Type of payment

Currency if not AUD Your partner’s share

Who pays it?
%

Amount per fortnight Date commenced (if known) 2 Description of asset

$ / /
Your partner’s
% Balance of loan(s)
share
Current market value taken to purchase
2 Type of payment

Currency if not AUD Your partner’s share

Who pays it? %

Amount per fortnight Date commenced (if known) If you need more space, provide a separate sheet with details.
$ / /
Your partner’s About your family
%
share
83 Do you and/or your partner have any children in your care under
3 Type of payment 20 years of age?
No Go to 89
Who pays it? Yes Go to next question

Amount per fortnight Date commenced (if known) 84 Do you and/or your partner get Family Tax Benefit and/or
Child Care Subsidy for the child(ren) in your care?
$ / /
No You and/or your partner may be eligible for Family
Your partner’s Tax Benefit and/or Child Care Subsidy.
%
share For more information, go to www.

[Link]/families
If you need more space, provide a separate sheet with details. Go to 88

Yes Go to next question

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 Taxable income for Family Tax Benefit and/or Child Care Subsidy purposes

85 Read this before answering the following questions.

We use your family income estimate to work out how much Family Tax Benefit and/or Child Care Subsidy we pay you.
Your estimated annual income should be based on your and your partner’s income components as listed in the tables.
For more information on what to include in your family income estimate, go to [Link]/familyincomeestimate
www.

Use the following table to estimate your and your partner’s annual taxable income for the current financial year.
If you did not get income from any of the following sources, write $0 in the appropriate boxes.

You Your partner

A Estimated taxable income from salary and wages $ $

B Estimated taxable income from Australian Government payments $ $

C Other estimated taxable income AUD AUD

Total estimated taxable income (total of A to C) = $ $

86 Provide details of how much you and your partner expect to get from any of the following sources in the current financial year.
If you do not get income from any of the following sources, write $0 in the appropriate boxes.
You Your partner
Estimated amount Estimated amount
A Exempt reportable fringe benefits $ $

Estimated amount Estimated amount

B All other reportable fringe benefits $ $

Estimated amount Estimated amount

C Reportable superannuation contributions $ $

Estimated amount Estimated amount

D Total net investment losses –$ –$

Estimated amount Estimated amount

E Tax free pensions and benefits $ $

Estimated amount Estimated amount

F Foreign income AUD AUD

Estimated amount Estimated amount

G Tax exempt foreign income AUD AUD

Estimated amount Estimated amount

H Child support you and/or your partner pay $ $

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 Eligible Child Care Subsidy hours

87 Read this before answering the following questions.

We use your and/or your partner’s activity levels to work out how much Child Care Subsidy we pay you.
Your estimated activity levels should be based on your and/or your partner’s activity components as listed below.
For more information, see how to manage your payment at [Link]/childcaresubsidy

Do you and/or your partner get Child Care Subsidy for your children?
No Go to next question
Yes Give details below
Use the following table to update your and/or your partner’s activity details for Child Care Subsidy for the fortnight that your child(ren)
attends approved child care.
Activity Tick if this Tick if this Total number of hours Date this activity will
applies to applies to spent on this activity start/started
you your partner per fortnight
Paid work Full-time / /

Part-time / /

Casual / /

Full-time / /

Part-time / /

Casual / /
Study / /
/ /
Training / /
/ /
Volunteering / /
/ /
Unpaid work experience or internship / /
/ /
Unpaid work in family owned / /
business
/ /
Setting up a business / /
/ /
Looking for work / /
/ /
Paid leave / /
/ /
Unpaid parental leave / /
/ /
Unpaid leave / /
/ /
None of the above

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88 Do you and/or your partner share the care of your children Checklist
with someone else and/or has the care arrangements of
children in your care changed since you last told us? 89 Which of the following forms and documents are you and/or your
No partner providing with this form?
If your care arrangements change, you will need
to contact us to update your details. Where you are asked to supply documents, provide original
Go to next question documents. In some circumstances, copies may be accepted
as detailed in the below checklist.
Yes You will need to complete and return a If you are not sure, check the question to see if you should
Details of your child’s care arrangement provide the documents.
(FA012) form.
Accommodation details (Mod AC) form
If you do not have this form, go to
(If you answered Yes at question 9)
www.

[Link]/forms
Income and Assets (Mod iA) form
(If you answered Yes at question 10, 11, 27 or 43)
Copies of payslip(s) from the date you became partnered
from each employer
(If you answered Yes at question 44)
Copies of documents with details of the fringe benefits
(If you answered Yes at question 45)
Seasonal, Contract and Intermittent Work Details
(SU496) form
(If you answered Yes at question 47)
Employment Separation Certificate (SU001) form,
letter from the employer or documents confirming your
business has stopped trading
(If you answered Yes at question 49)
Employment Separation Certificate (SU001) form or letter
from the employer
(If you answered Yes at question 50 or 51)
Business details (Mod F) form and Real estate details
(Mod R) form for each property
(If you answered Yes at question 52)
Copy of evidence of the vesting
(If you answered Yes at question 54)
Private Trust (Mod PT) form
(If you answered No at question 57)
Special Disability Trust (Mod SDT) form
(If you answered Yes at question 57)
Copy of the most recent financial documents
(If you answered No at question 58 and/or question 63)
Copy of evidence of deregistration
(If you answered Yes at question 60)
Private Company (Mod PC) form
(If you answered No at question 62)
Compensation and damages (Mod C) form
(If you answered No at question 65)
Copy of the policy document and the latest statement for
this policy
(If you answered Yes at question 66)
Copies of documents with details of payments from
outside Australia
(If you answered Yes at question 67)
Copies of documents with details of bank, building
society or credit union account balances
(Required at question 68)

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 Continued Privacy notice
Real estate details (Mod R) form
(If you answered Yes at question 73, 74, and/or 75 or 90 You and your partner need to read this
if required at question 77) Privacy and your personal information
Copies of the latest statements for superannuation funds The privacy and security of your personal information is
important to us, and is protected by law. We need to collect
and retirement savings accounts or, financial statement
this information so we can process and manage your
including income tax return and member statement for applications and payments, and provide services to you.
SMSFs and SAFs We only share your information with other parties where you
(If you answered Yes at question 78) have agreed, or where the law allows or requires it. For more
Copies of the latest statement for each shareholding information, go to [Link]/privacy
www.

listed on a stock/securities exchange

(If you answered Yes at question 79)
Declaration
Copies of insurance policy documents and latest
statements
(If you answered Yes at question 80)
91 We declare that:
• the information we have provided in this form is complete
Copy of the most recent statement/certificate that gives and correct.
details for each type of payment We understand that:
(If you answered Yes at question 81) • if submitting this form as part of a claim, the claim may not
Details of your child’s care arrangement (FA012) form be accepted, unless supporting documents are lodged at
(If you answered Yes at question 88) the same time as the claim. The only exception will be if we
are waiting for medical evidence or other documents from a
third party.
• Centrelink can make relevant enquiries to make sure we get
the correct entitlement.
• giving false or misleading information is a serious offence.

Your signature (the person named at question 2)

On completion of this form,

print and sign by hand

Date
/ /

Your partner’s signature (the person named at question 13)

On completion of this form,

print and sign by hand

Date
/ /

Next steps
Check that you have done the following:
• answered all the questions that you need to
• provided all requested information and any additional forms.
If your partner does not have a tax file number, go to
www.

[Link] for more information.

• you and your partner have signed and dated this form.
• refer to ‘Returning this form’ on page 2 of the Notes.

Print Clear

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